This is a hot topic among therapists, and certainly among potential clients who may be frustrated by this. In an ideal world you could see whichever therapist you wanted, he or she would be taking new clients, and that therapist would take your insurance. And, you would owe not more than a small copay per visit.
Well, this is not an ideal world, and nor is our healthcare system. Some therapists are booked up, even through your insurance it could be expensive to see one (if you have a high copay or a deductible to meet), and some therapists simply opt out of the insurance system. This means they work on a private-pay or fee-for-service basis. Like your hair stylist, mechanic, or plumber, they provide a service and you pay their fee each time.
In private pay situations, most therapists will provide a statement of your visits which you can submit to your insurance company to recoup some of the cost via out-of-network benefits- provided that your plan offers out-of-network benefits. For example, if you paid $150 a visit, your insurance could reimburse you something like 65% of “the usual and customary rate” (what they believe a session should cost…let’s just say 65% of $100), giving you back $65. Some people have OON benefits, some don’t. You would need to check to see if it applied to you. And sometimes these fees will at least be applied to a deductible, while other times not. Again, you would need to check.
To provide context, I do choose to work with a number of insurance companies. I can’t accept all of them, as it would take a lot of work to get into the networks (if they were all taking new providers) and to stay credentialed with them, and some offer low rates of reimbursement that I cannot afford to accept. As a therapist my job is to help people… but I am also a business owner with bills, a family to support, and an eventual retirement to plan for.
But here are some of the reasons why some therapists choose not to work with insurance companies. As an aside, more physicians are doing this as well, offering what they call concierge medicine. I would imagine some dentists or other healthcare providers are doing the same. So here are some of the reasons…
Low reimbursement rates: Some insurances simply offer low rates for an hour (about 50 minutes) of therapy or other services. These may be significantly lower than other companies, making them less appealing for therapists to want to accept.
Difficulty in working with insurance companies: As in any other industry, some companies are more difficult to work with than others- “red tape” or “hoops” to jump through, policies that create inconvenience or more work, lack of responsiveness to issues, and so on. Some companies may have a reputation for this, while others a therapist may have decided to stop accepting due to their own past experience.
Delays in payment: Some companies take months (1-3) to pay claims, especially if they require that you submit paper claims by mail. This is not the norm, as most companies I work with pay me weekly, on a predictable schedule. However, my motivation for writing this article was one particular company I have been working with. As of today (1/8/19) I have not been paid for any claims dating back to August (2018)! After several attempts to follow up and being told “worry, we’re behind”, still no payment. I am beyond frustrated. This is atypical, as I have said, but enough to lead some therapists to limit their insurance contracts or to avoid them entirely. I have decided to stop working with that one company.
Time involved with billing and administrative tasks, possibly requiring staff: If you see several clients per week with insurance it does take some time to do billing and other administrative work. Some therapists do this themselves, while others hire someone to do this, either part-time or full-time. The real time comes in when there is a billing issue- unpaid claims (as I mentioned before), claims needing to be resubmitted for some reason, verifying benefits, and providing clients with documentation regarding their visits. Some therapists don’t want to do this work, or they want to keep their overhead low and avoid hiring staff.
Poor customer service: As with any other industry, some insurance companies take very long to get a live representative on the phone, and when you do, some are more helpful than others. Some push automated systems, which may or may not be helpful. Again, not everyone wants to deal with this.
Wanting to make a very good living: Who can fault someone for that, right? When a healthcare provider contracts with an insurance company, he or she agrees to accept a lower rate than their usual fee to see clients with that insurance. It can be beneficial because that provider will get more referrals and because more people can then see them using their insurance. For example, a therapist’s regular rate may be $150 per hour session, whereas a typical insurance reimbursement (including any copays) may be $95. That means the client is getting a $55 discount on that service, and the therapist is providing about the same service for about 66% of the fee. Some therapists, however, are able to get enough clients without being in insurance networks, which of course would bring in more income. This is often because they are well-established, regarded as an expert and clients may come from a distance to see them, or they work in a well-to-do area where more clients can afford to pay the full fee.
Wanting to see fewer clients per week: Related to the last point (to make a good income) many therapists who work with insurance companies find themselves seeing more clients per week. This can lead to feeling overwhelmed and even burnt out, or at least some may fear this. As a result, some therapists may choose not to work with insurance companies, because they can make a comparable income by seeing 20 clients weekly this way, vs. 30 or 35 through insurance. This allows for more flexibility, more time spent on other activities (like teaching or writing), and perhaps more time spent on each client- and, of course, more time doing things other than working.
There may be other reasons, as each provider makes these decisions for him or herself, but these are the primary reasons I have heard.
If you prefer to use your insurance, or need to, and you have a provider in mind, check with him or her about network participation and what costs you might expect. You can also call your insurance company or go online, or you can search for a therapist using a directory like Psychology Today. And if a therapist does not accept your insurance, you could ask your insurance company about out-of-network benefits or give some thought to whether or not you can afford to see a therapist privately. For example, seeing a therapist this way would be more affordable if you needed short-term therapy or if it might be appropriate to see him or twice a month, rather than every week. Some issues are short-term in nature or can be helped with just a few visits, while others require more ongoing care.
I hope this provided some insight into this situation, and for anyone thinking of seeing a therapist or who is having difficulty finding one, please persist. There are many great providers out there, and certainly one who could be the right fit for you.